tbuckley/cabot-search huggingface dataset:
System-level barriers and facilitators to cancer rehabilitation delivery for children with cancer.
Authors: Maria Chang Swartz, Donna M. Kelly, Keri L. Schadler, Clark R. Andersen, Stephanie J. Wells, Shiming Zhang, Alakh Rajan, Amy Heaton, Karen Moody
Journal: Journal of Clinical Oncology (2022)

81 Background: Up to 20% of childhood cancer survivors suffer from a significant physical function impairment due to cancer or cancer treatment. Early intervention with Occupational Therapy (OT) and Physical Therapy (PT) increases engagement in personal care, leisure interests, school-based tasks, return to work, and prevents cognitive decline. Despite this, less than 30% of childhood cancer survivors receive PT services. To date, facilitators and barriers to implementing cancer rehabilitation (CR) for pediatric cancer survivors have not been adequately explored. Thus, the aim of this research was to identify system-level barriers and facilitators to CR delivery based on surveys completed by hospital administrators, oncology physicians, advanced practice providers, and OT/PT therapists. Methods: A cross-sectional method was employed. Three previously published cardiac rehabilitation delivery instruments specific for administrators, OT/PT therapists and clinical providers respectively were adapted to evaluate CR delivery. All surveys used a 5-point Likert-type response format (e.g., 1 = strongly disagree to 5 = strongly agree). Surveys ranged from 12 items (therapist survey) to 23 items (administrator survey). Questions pertained to knowledge, attitudes, and perceptions regarding CR. Results: A total of 20 administrators (mean age, 49.95 years old, 65% non-Hispanic White, 65% female), 20 providers (mean age, 43.4 years old, 71.4% non-Hispanic White, 67% female), and 20 therapists (mean age, 38.3 years old, 70% non-Hispanic white, 84% female) completed surveys. Administrators’ results indicated mid-range CR knowledge (median: 3.5; IQR 2,5), and all perceived CR as important or extremely important to outpatient care (median: 5; IQR 4,5). Limited insurance coverage and lack of space were the top barriers identified by administrators. Eighty percent of providers endorsed that clinical practice guidelines promote CR referral (median 4; IQR 4,5) and none reported being skeptical of CR benefits. Provider-identified barriers included an inconvenient referral process, lack of CR patient-education materials, and inadequate information on external CR resources. Therapists identified rate of absenteeism and referral rates as barriers to CR. Ninety percent of therapists reported hybrid CR delivery (supervised and unsupervised exercise) could facilitate CR participation (median 4; IQR 4,4). Conclusions: System-wide, there was adequate knowledge and positive perceptions and attitudes regarding CR. However, we identified multiple barriers presenting opportunities for multilevel interventions. These included: insurance coverage advocacy, streamlining referral processes to CR services, providing information on external CR programs, providing patient education materials, and leveraging hybrid CR delivery to optimize participation.
Quality improvement project: Implementation of I-PASS, a structured patient hand-off tool to improve communication, increase patient safety, and prevent burnout among palliative care providers at a comprehensive cancer center.
Authors: Jaya Sheela Amaram-Davila, Holly A. Stewart, Monica Aceves, Kimmie Tallie, Olga Fleckenstein, Mohamed Ait Aiss, Maria Franco-Vega, Shalini Dalal, Eduardo Bruera
Journal: Journal of Clinical Oncology (2022)

65 Background: Communication among the health care providers plays a crucial role in team-based practices, and a standardized communication platform is essential. Our palliative care consult service (PCCS) at a university-based cancer center manages cancer-related symptoms. The handoff process among the providers takes place via encrypted emails shared among the providers. The current demand for palliative care (PC) among the cancer population led to increased patient encounters and associated handoff emails. Numerous handoff emails (sometimes up to 25-30/day) can lead to missing/overlooked information, cause burnout among the providers, and affect patient safety. Studies have shown that implementing I-PASS into clinical practices has significantly reduced medical errors without increasing documentation time. We aimed to improve communication among the PC providers, prevent burnout and increase patient safety by using a built-in I-PASS handoff tool on electronic medical records (EMR). Methods: In January 2021, we formed a team to develop a quality improvement (QI) project to implement I-PASS for our PCCS at our institution. The institutional Quality Improvement Assessment Board approved this QI project. Our team started with Plan, Do, Study, Act. After extensive brainstorming, we mapped out the Cause-and-effect diagram (Fishbone). We laid out a Process mapping through a flowchart and Feasibility impact matrix. The implementation process took place in 4 phases. Phase 1: A per-implementation survey. Phase 2: Extensive training sessions for PC clinicians, both, 1:1 and group sessions. Phase 3: October 2021 I-Pass implementation went live. Phase 4: post-implementing survey to assess provider reception. Results: Based on real-time assessment on EMR, at four months mark, we reached the 100% utilization goal for I-PASS among PC clinicians. In Pre vs. Post-implementation survey, providers perceived they could identify their patient's related information, save time, update handoff daily and locate their assignments without any efforts on I-PASS compared to email handoff (p &lt; 0.0001). Overall, 95% of the PC providers found I-PASS helpful. Conclusions: Standardized communication tools such as I-PASS have proven safe and effective and help prevent provider burnout by improving overall workflow. Future studies need to focus on steps to continue developing tools to help modify the handoff on Smartphone EMR applications such as HAIKU.
Real-world practice patterns in multidisciplinary squamous cell carcinoma care at community oncology centers.
Authors: John M. Kirkwood, Andrew C. Krakowski, Jeffrey D. Carter, Cherilyn Heggen, Kelly E. McKinnon
Journal: Journal of Clinical Oncology (2022)

261 Background: As the incidence of cutaneous squamous cell carcinoma (cSCC) continues to rise and newer systemic therapies become available, coordination of care between dermatologists and oncologists will be vital to provide quality, patient-centered care. Methods: Between 8/17/2020 and 11/30/2020, we surveyed dermatology team members (n = 50) and oncology team members (n = 54) at 5 community oncology practices to assess current practices, challenges/barriers, and areas for improvement in multidisciplinary care of cSCC. Providers then participated in audit/feedback educational sessions and developed action plans to address identified gaps. Results: A majority of providers (72%) reported “very low” or “low” levels of care coordination between oncology and dermatology teams (5-point Likert scale). The three main barriers identified by dermatology/oncology teams included lack of relationship to other specialties (36%/47%), lack of multidisciplinary tumor board (30%/36%), and difficulty with patient navigation to follow-up and monitoring (44%/29%). In addition, lack of administrative support (30%/47%), lack of time (54%/42%), and high case load (32%/16%) hindered multidisciplinary tumor board meetings. Overall, dermatology teams reported lower confidence in making treatment decisions for patients with advanced cSCC compared to oncology teams. Specific strategies were identified to bridge these gaps and improve cSCC care including improving electronic communication, coordinating treatment plans with multidisciplinary teams, integrating educational seminars between oncologists and dermatologists, and finding better multimodality therapeutic options. Conclusions: These findings reveal important challenges in multidisciplinary care of cSCC in community oncology clinics. The identified gaps may inform future implementation science initiatives, and represent key opportunities for improvement in cSCC patient care.[Table: see text]
Bone health program: A community cancer center's experience.
Authors: Manasa Anipindi, Tejaswi Venigalla, Hussein Al-Sudani, Noelle Provenzano, Rafal Ali, Madiha Atif Gilani
Journal: Journal of Clinical Oncology (2022)

360 Background: Aromatase inhibitors (AI) are an essential treatment for postmenopausal women with hormone receptor-positive breast cancer in the adjuvant setting. Estrogen deficiency caused by AIs has adverse effects on bone health. Studies reveal that 5 years of treatment with anastrozole led to 6.1% of bone loss at the lumbar spine and 7.2% at the hip. The aim of the project is to identify the current degree of attention to bone health and skeletal-related complications in women with early-stage breast cancer stages I-III that are on AIs at a community cancer center at Einstein Medical Center Montgomery. Methods: This is a retrospective chart review of 63 patients ages 50-85 diagnosed with early-stage I-III breast cancer on an AI in the adjuvant setting. Patients who started on an AI between January 2013 through December 2017 were included. Data on Dual-energy X-ray absorptiometry scans (DEXA) and treatment at baseline, 2-years, and 4-years were analyzed. We followed to see if they had a DEXA scan every 2 years after the baseline DEXA scan for the following 4 years and analyzed information on their bone health. Results: Patients included were on an AI throughout the 4 years. The median age was 60.2 years. 46/63 (73%) had a baseline DEXA scan. Out of these, 12/63 had a normal bone density. 28/63 had osteopenia, of which 16/28 were treated. 6/63 had osteoporosis and only 2/6 were treated. After 2 years, 39/63 (61%) had a 2-year DEXA scan. Of these, 8 had a normal bone density. 26/63 had osteopenia of which 21/26 were treated. 5/63 had osteoporosis and all 5 were treated for this. At 4 years, 40/63 (63%) had baseline DEXA scans. 9/63 had a normal bone density. 21/63 had osteopenia, out of which 17/21 were treated. 10/63 had osteoporosis of which 5/10 were treated. Conclusions: Patients who are being treated with aromatase inhibitors should be evaluated for baseline bone health prior to initiating AIs and every 2 years thereafter. Treatment with bisphosphonates or RANK ligand inhibitors is recommended at an earlier T-score compared to post-menopausal osteoporosis in the absence of breast cancer. In our study, we noticed that the number of patients who did not receive a DEXA scan at the correct time points increased during the period of treatment with the AI. About 53% of patients had osteopenia or osteoporosis at the time of initiation of AIs. The amount of osteoporosis in patients increased from 9.5% at baseline to 15.8% at the 4-year point. This data indicates the need for proper guidelines on DEXA scans and interventions for this patient population. Current interventions planned are patient education Flyers, a patient risk factor checklist in the EMR (Electronic Medical Record) and prompts to review the status of the DEXA report when ordering AIs.
“It sounds very negative”: Patient perspectives on de-escalation of treatment concept and language.
Authors: Courtney J. Andrews, Valerie Lawhon, Antonio C. Wolff, Lauren P. Wallner, Mary Lou Smith, Gabrielle Betty Rocque
Journal: Journal of Clinical Oncology (2022)

254 Background: As the combination of systemic and targeted chemotherapies is associated with severe adverse side effects and long-term health complications, there is interest in reducing treatment intensity for patients with early-stage breast cancer (EBC). Currently, this approach is being described as “de-escalation,” though there is some concern that this language and framing are not well understood or preferred by patients. Methods: We collected qualitative interview data from twenty-four patients with Stage II-III breast cancer and sixteen patient advocates. Interviews explored interest in participation in clinical trials testing reduced amounts of chemotherapy, reactions to the word “de-escalation,” and preferred ways to describe this approach and its anticipated benefits. Interviews were audio-recorded and transcribed, and researchers used qualitative content analysis to code for dominant themes. Results: Twenty-three participants (57.5%) expressed interest in participating in a trial of reduced chemotherapy. However, 60% of participants had a negative response to the word “de-escalation,” including 78% of respondents that said they were interested in the concept. To describe this approach, respondents tend to prefer words like “personalization,” “optimization,” or “reduced chemotherapy.” Participants also expressed the importance of provider-patient communication, clear and simple language, sharing the decision-making process, and continued support throughout and after treatment in their consideration of trials testing lower amounts of chemotherapy. Conclusions: Among individuals with EBC, there is significant interest in alleviating treatment-related toxicity by reducing chemotherapeutic intensity. Patients are more apt to feel comfortable participating in trials testing this approach if they are framed in terms of customizing treatment to the individual patient and added benefit—reduced toxicities, higher quality of life during treatment and lower risk of long-term complications—rather than in terms of taking treatments away or doing less than the standard of care. “De-escalation” is not an ideal word to describe these trials as many associate this word with giving up in the war against cancer. Instead, participants prefer positive, patient-centered language. This information will be useful to providers in considering how best to describe de-escalation clinical trials to eligible patients in ways that avoid therapeutic misconception and facilitate the shared decision-making process regarding treatment.
Promoting digital health equity through remote patient monitoring: A feasibility study.
Authors: Alaina J. Kessler, Melanie Besculides, Carol Kisswany, Mark Liu, Asem Berkalieva, Madhu Mazumdar, Cardinale B. Smith, Ksenia O. Gorbenko
Journal: Journal of Clinical Oncology (2022)

441 Background: Remote patient monitoring (RPM) is a form of telemedicine involving collection and transmission of health data from patients to providers using non-invasive digital technology. RPM may offer earlier recognition of clinical deterioration to help reduce acute care use and improve healthcare outcomes. Studies of digital interventions in oncology have demonstrated reduction in symptom distress and unplanned hospitalizations but lack focus on minority patients. Studies of telehealth aiming to address disparities have not focused on patients with cancer. In this pilot study, we evaluated the feasibility of RPM among patients with cancer at a large urban medical center serving a racially and socioeconomically diverse population. Methods: We partnered with Current Health to provide an FDA-approved RPM wearable device, which included a secure HIPAA-compliant platform, to collect heart rate, temperature, respiration, oxygen saturation, and blood pressure. The kit included broadband access and a tablet to provide telehealth services. Oncology coordinators determined clinical inclusion and exclusion criteria of RPM initiation for patients. A centralized team of Nurse Practitioners (NPs) monitored alarms. Clinical alarms indicated abnormal vital signs; technical alarms indicated no data transmission for a 12-hour period. We measured feasibility by recruitment and retention, and used descriptive statistics to describe the study population, time enrolled on RPM, and alarms. Results: To date, we enrolled 39 patients on the RPM platform over a 14-month period with a weekly census of 10 patients undergoing RPM monitoring. Of the 39 patients, 19 (49%) were white, 10 (26%) Black, and 5 (13%) Asian; 3 (8%) patients identified as Hispanic. Nine (23%) patients had either primary or secondary Medicaid insurance. The average age was 57.9 years. The majority of patients (95%) had hematologic malignancies, all of whom were enrolled on hospital discharge. The mean length of time per patient enrolled with the device was 21.7 days. Over 14 months, there were 607 technical and 118 clinical alarms with an average of 2 clinical alarms per week addressed by NPs by phone, indicating low clinician burden. Conclusions: This pilot study demonstrated the feasibility of RPM in patients with cancer at home. Future studies should focus on equity-driven implementation of RPM in patients with cancer, as well as patient-reported and healthcare utilization outcomes to identify best practices in telemedicine implementation. RPM has promise to deliver high quality and equitable cancer care.
Improving the uptake of prehabilitation interventions for older adults prior to cancer treatment using telehealth in the Geriatric Oncology One-Stop Clinic.
Authors: Yean Shin Ng, Noorhanah Mohd Said, Matthew Zhixuan Chen, Wan Nghee Eng, Natalie Mun Wai Ling, Jia Li Low, Yao Yao, Yijun Loy, Meiling Chun, Wei Yee Wong, Jie Xin Ong, Vivian Luah, Shien Ling Angela Pang, Francis Ho
Journal: Journal of Clinical Oncology (2022)

55 Background: Prehabilitation in older patients aged ≥ 65 years undergoing cancer surgery and systemic therapy is crucial in reducing treatment complications and improving physical health, psychological well-being, quality of life (QOL) and cancer-related outcomes. However, a majority of older patients (80%) attending our Geriatric Oncology (GO) One-Stop clinic do not receive same day Comprehensive Geriatric Assessment (CGA)-directed Allied Health Interventions (AHI) for prehabilitation during their First Visit (FV). Objectives: The objective of this study is to increase the uptake of same day CGA-directed AHI for prehabilitation from 20% to 60% using telehealth. Methods: Older patients planned for an FV at the GO One-Stop clinic in an academic tertiary center, the National University Cancer Institute, Singapore (NCIS) were recruited. Our workflow was revised so that all FV patients underwent CGA via telehealth prior to the physical visit. Based on the preliminary CGA findings, a multidisciplinary geriatric oncology board planned for prehabilitation interventions which would be performed on the same day as the physical visit. Interim follow-up via telehealth by GO nurses helped to monitor patients for treatment-related toxicities and development of new geriatric syndromes. QOL was assessed during the FV and 3 months later. Results: Two hundred seventy-five patients were recruited from July 2020 to January 2022. 60% (n = 165) received prehabilitation interventions in the One-Stop clinic. The average time spent per visit was shortened from 4 hours to 2.5hours, but completed interventions on same day rose from 1 to 3. The proportion of patients who responded that they benefited from the program on the patient satisfactory survey remained high at 96%. 84.8% were satisfied with the hybrid telehealth model and 80.8% of them reported a maintained or improved QOL after being enrolled into the program. Conclusions: Adoption of telehealth for CGA is a feasible and effective method in improving prehabilitation interventions uptake for GO patients. GO hybrid model of care is a sustainable practice with no additional cost incurred.
Access to Medicaid dental services and distant-stage oral cancer diagnoses in Utah: A quasi-experimental approach.
Authors: Jason Semprini
Journal: Journal of Clinical Oncology (2022)

106 Background: Late detection may contribute to disparities in oral cancer outcomes, as most low-income oral cancer patients are diagnosed at distant stages. Because dentists are the most likely provider to screen for oral cancer, access to Medicaid dental services could improve outcomes. However, states are not mandated to cover adult Medicaid dental benefits. In 2010, Utah’s Medicaid program added dental benefits. My study leverages this policy change to test if dental coverage is associated with distant stage diagnoses and if this association changes with the number of dentists per capita. Methods: I analyzed SEER data for all oral cancers diagnosed between 2007-2013. The outcome is a binary variable, indicating if the oral cancer patient was diagnosed at a distant stage. All analyses control for age, race, and gender as well as state and year fixed-effects. Under a Difference-in-Differences design, where DD = Post2010*Utah, I estimate the effect of adding dental coverage for Medicaid enrollees in Utah compared to Medicaid enrollees in states that did not change their Medicaid program. Then, to account for differential trends, I implement a Triple Differences design, where DDD = Post2010*Utah*Medicaid, and estimate the effect of adding dental coverage for Medicaid enrollees in Utah compared to adults in Utah who are not on Medicaid. Finally, I interact the DDD variable with a variable measuring Utah's dentists per 100,000 population (county-level data from AHRQ). Results: Compared to Medicaid enrollees in other states, adding Medicaid dental coverage in Utah was associated with a decline in the probability of a distant-stage oral cancer diagnosis (DD = -0.046; ci = -0.078, -0.014). The Triple Difference result was similar (DDD = -0.074; ci = -0.107, -0.041). The heterogeneity analysis reveals that the association between adding Medicaid dental coverage and distant stage diagnoses are small and insignificant in Utah counties without dentists. However, the interaction term between adding dental coverage and dentists per capita yields a significant decline for every additional dentist in the county (DDD*Dentists/100,000Capita. = -.001 ci = [-0.002, -0.0009]. Putting these results into context, the marginal effect of adding dental coverage in counties with 80 dentists/100,000 is associated with a 0.104-percentage point decline in distant diagnoses: a 20% decline relative to pre-2010 rates. Conclusions: Access to dental services could improve outcomes for low-income oral cancer patients, but the persistent barriers to dental care may perpetuate disparities.